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Lipid transfer protein syndrome (LTPS) results from a primary sensitization to LTP belonging to the PR-14 family of pathogenesis-related PR-proteins which are plant food allergens, stable against heat and digestive enzymes, and can induce systemic reactions of urticaria, angioedema, and anaphylaxis. Here, we report a case series of seven patients with nsLTP syndrome. Our six cases of LTPS were significantly sensitized to Prosopis juliflora and Holoptelea integrifolia and one case was sensitized to H. integrifolia only. In our seven cases, we hypothesized that symptoms of hypersensitivity reaction to foods were due to cross-reactivity by IgE reactive protein of ns-LTP as a major allergenic protein in foods.

Thromboinflammation is a still not well-understood phenomenon, which has recently come to the foreground as a function of its relevance in the pathophysiology of coronavirus disease 2019 (COVID-19). The patient described in the present case report exhibited acute fever, giant urticaria, elevated acute phase reactants, and very high d-dimer levels, thus characterizing thromboinflammation. She was diagnosed as a COVID-19 suspect case, which was not confirmed; urticarial vasculitis was ruled out. Homeopathic treatment was started with the earliest clinical manifestations, resulting in rapid and drastic reduction of inflammation and hypercoagulability within the first 12 hours, and full recovery on 10-day follow-up assessment. This case demonstrates the effectiveness of homeopathy in a severe acute disorder, and points to the need to include laboratory testing in homeopathic clinical assessment to achieve an accurate picture of disease, and to avoid the risk of passing over life-threatening disorders.

We report a case of a 75-year-old man with facial edema that also affected the periorbital area who was admitted to the hospital with the suspected diagnosis of Quincke's edema. The diagnosis of cutaneous angiosarcoma was made by microscopic examination and immunohistochemical staining. Chemotherapy was initially initiated because the angiosarcoma was unresectable and the radiation situation was difficult. Therapy has to be switched to second and third line therapy due to disease progression. The case illustrates the complexity of diagnosis and therapy in patients with cutaneous angiosarcoma.Es wird über den Fall eines 75-jährigen Patienten mit einer Gesichtsschwellung v. a. periorbital berichtet, der unter der Verdachtsdiagnose eines Quincke-Ödems stationär aufgenommen wurde. Probebiopsien ergaben das Vorliegen eines kutanen Angiosarkoms. Bei nicht resezierbarem Befund und schwieriger Bestrahlungssituation wurde zunächst eine Chemotherapie eingeleitet. Im Verlauf erfolgte bei Befundprogress die Therapieumstellung auf Zweit- und Drittlinientherapie. Der geschilderte Fall verdeutlicht die Komplexität bei der Diagnostik und Therapie bei Patienten mit kutanem Angiosarkom.

Hereditary angioneurotic oedema is an autosomal dominant disease associated with serum deficiency of functional C1-inhibitor. It is characterized by periodic swelling of subcutaneous tissues, abdominal viscera and upper airways. Lethal acute episodes of oedema can occur during anaesthesia and surgery. It is essential to prepare such patients before surgery. This article describes a case and the various preventive measures used to avoid acute episodes during anaesthesia for urgent surgery for mesenteric ischemia. In emergency situations where C1 inhibitor concentrate is not available, fresh frozen plasma (FFP) can be used as an alternative, as it also contains C1 inhibitor, corticosteroids, antihistamines, and epinephrine can be useful adjuncts but typically are not efficacious in aborting acute attacks. Prophylactic management involves long-term use of attenuated androgens or antifibrinolytic agents (Tranexamic acid).Their various indications are discussed.

Background Isolated angioneurotic edema of the uvula is termed Quincke’s disease. It is a rare clinical disorder of acute onset with few known causes. It may be encountered in any emergency setup and must be dealt with rapidly and with utmost vigilance for prevention of progression and complications. Case presentation A young adult, 3 months post Frey’s procedure for chronic pancreatitis, presented with acute onset throat discomfort and gagging progressive over 8 h. Examination showed isolated edematous hyperemic uvula with normal oropharyngeal structures and adequate airway. Prompt antihistaminic and corticosteroid therapy caused relief of symptoms over 2 h with no recurrences. Conclusion Any symptom suggesting orofacial edema must not be trivialized. Awareness about this rare but acute condition, even in the background of unknown etiology, in all medical personnel is essential. Early diagnosis with appropriate management can prevent life-threatening airway obstruction and hypoxemia.

On 23 September 1919, Sir William Osler, after a telephone call from his friend Dyson Perrins, went to Glasgow where he saw a 40-year-old woman, Bethia Fulton Martin, in consultation with three local physicians. Osler called it “one of those remarkable Erythema cases (all sorts of skin lesions and three months on and off consolidation of both lower lobes).” Mrs Martin died 114 days later; her death certificate listed “angioneurotic oedema with chronic nephritis” and “tuberculous enlargement of the mediastinal lymph nodes.” Osler died 18 days before Mrs Martin of complications from a respiratory infection acquired on his way home from Scotland. We discuss factors that possibly prompted Osler to go to Scotland, including his role with the newly formed University Grants Committee, and the differential diagnosis of the case, which is mainly between systemic lupus erythematosus and Henoch-Schönlein purpura.

The skin clinical phenotypes of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity (NH) are very heterogeneous with several syndromes after NSAID intake, which include different symptoms, different organ involvement and different associated concomitant diseases and possibly different underlying pathophysiology and mechanisms. Making a correct diagnosis in NH is an exciting journey for any allergist. Thus, to classify these diseases properly will be pivotal for appropriate diagnostic and management strategy. Treatment modalities are depending on the clinical phenotypes of NH and they will embrace for each patient: the avoidance of culprit NSAID, the finding of well-tolerated NSAID and in certain cases, desensitization procedures when the NSAID treatment was absolutely needed as well as the control of associated diseases such as spontaneous chronic urticarial or allergic respiratory diseases. This review updates the recent evidence of classification, diagnostic strategies, and management of skin NSAID hypersensitivity reactions.

Urticarial eruptions and angioedema are the most common cutaneous reactions in patients undergoing mRNA COVID-19 vaccinations. The vasoactive peptide bradykinin has long been known to be involved in angioedema and recently also in urticaria. Bradykinin is mainly catabolized by angiotensin-converting enzyme (ACE), which is inhibited by ACE inhibitors, a commonly employed class of antihypertensive drugs. We evaluated the risk of developing urticaria/angioedema after inoculation with the BNT162b2 mRNA COVID-19 vaccine in a population of 3586 health care workers. The influences of ACE inhibitors and selected potential confounding variables (sex, age, previous SARS-CoV-2 infection, and allergy history) were evaluated by fitting univariate and multivariable Poisson regression models. The overall cumulative incidence of urticaria/angioedema was 1.8% (65 out of 3586; 95% CI: 1.4–2.3%). Symptoms were mild, and no subject consulted a physician. Subjects taking ACE inhibitors had an adjusted three-fold increased risk of urticaria/angioedema (RR 2.98, 95% CI: 1.12–7.96). When we restricted the analysis to those aged 50 years or more, the adjusted RR was 3.98 (95% CI: 1.44–11.0). In conclusion, our data indicate that subjects taking ACE inhibitors have an increased risk of urticaria/angioedema after vaccination with the BNT162b2 mRNA COVID-19 vaccine. Symptoms are mild and self-limited; however, they should be considered to adequately advise subjects undergoing vaccination.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the main triggers of drug hypersensitivity reactions, probably due to their high consumption worldwide. The most frequent type of NSAID hypersensitivity is NSAID cross-hypersensitivity, in which patients react to NSAIDs from different chemical groups in the absence of a specific immunological response. The underlying mechanism of NSAID cross-hypersensitivity has been linked to cyclooxygenase (COX)-1 inhibition causing an imbalance in the arachidonic acid pathway. Despite NSAID-induced acute urticaria/angioedema (NIUA) being the most frequent clinical phenotype, most studies have focused on NSAID-exacerbated respiratory disease. As NSAID cross-hypersensitivity reactions are idiosyncratic, only appearing in some subjects, it is believed that individual susceptibility is under the influence of genetic factors. Although associations with polymorphisms in genes from the AA pathway have been described, no previous study has evaluated the potential role of cytosolic phospholipase A2 (cPLA2) variants. This enzyme catalyzes the initial hydrolysis of membrane phospholipids to release AA, which can be subsequently metabolized into eicosanoids. Here, we analyzed for the first time the overall genetic variation in the cPLA2 gene (PLA2G4A) in NIUA patients. For this purpose, a set of tagging single nucleotide polymorphisms (tagSNPs) in PLA2G4A were selected using data from Europeans subjects in the 1,000 Genomes Project, and genotyped with the iPlex Sequenom MassArray technology. Two independent populations, each comprising NIUA patients and NSAID-tolerant controls, were recruited in Spain, for the purposes of discovery and replication, comprising a total of 1,128 individuals. Fifty-eight tagSNPs were successfully genotyped in the discovery cohort, of which four were significantly associated with NIUA after Bonferroni correction (rs2049963, rs2064471, rs12088010, and rs12746200). These polymorphisms were then genotyped in the replication cohort: rs2049963 was associated with increased risk for NIUA after Bonferroni correction under the dominant and additive models, whereas rs12088010 and rs12746200 were protective under these two inheritance models. Our results suggest a role for PLA2G4A polymorphisms in NIUA. However, further studies are required to replicate our findings, elucidate the mechanistic role, and evaluate the participation of PLA2G4A variants in other phenotypes induced by NSAID cross-hypersensitivity.

Urticaria is a fleeting papulous edematous pruritic rash on the skin, most often caused by an allergic reaction (food, drugs, insect bites, etc.). It can be acute, lasting less than 6 weeks or chronic, with recurrent episodes for more than 6 weeks. Chronic urticaria (UC) is a frequent reason for consultation. Patients management is often difficult due to its significant impact on the quality of life, its potential association with many underlying diseases and a sometimes insufficient response to first line treatment. The prevalence of urticaria in the general population is 0.6%-1.3%. Women are more frequently affected than men (3.8 times). Therapy is focused on reducing pruritus, size, number and frequency of lesions and is based on antihistamines and avoidance of exposure to contributing factors. We here report a case of chronic giant urticaria on the gluteal region in a 36-year-old office secretary with a history of chronic urticaria treated with Loratadine (10 mg tablet, once daily), presenting with edematous pruritic papules on the buttocks occurred more than 3 days before. Physical examination showed large erythematous edematous pruritic papules coalescing into large plaques on both buttocks. The largest plaques measured 25/20 cm, while the smallest 4 cm/3cm. Complete blood count was performed, which showed leukocytosis (mainly eosinophilic polynuclear leukocytosis). The diagnosis of urticaria was retained based on clinical lesions. The patient received 40mg Solumedrol for injection (2 ampoules for 5 days) and Bilastine (20 mg tablet per day). Outcome was favorable under treatment, with complete remission of lesions and disappearance of pruritus.

Angioedema with macroglossia is a rare complication of anesthesia. We present a clinical case of post-operative development of angioedema presenting as macroglossia in a patient receiving chronic therapy with lisinopril, who developed symptoms in the early post-operative period following surgery in a lateral position, when a laryngeal mask airway was used. Possible mechanisms of angioedema and macroglossia development in our patient are discussed along with potential underlying predisposing mechanisms and available therapeutic approaches.

Introduction The use of hair dye for deliberate self-harm is seen in many parts of the world. Paraphenylenediamine (PPD) is the main constituent of hair dye formulations and is found to be highly toxic. The other constituents are resorcinol, propylene glycol, sodium ethylene diamine tetra acetic acid, preservatives and perfume. Clinical features of PPD poisoning include severe cervicofacial odema, chocolate colored urine, oliguria and shock. Management is mainly supportive and there are no specific antidotes. Case report A young lady was brought to ED with complains of sudden onset swelling of chin, neck and tongue. She was sitting upright with hoarseness of voice. She had edema over her chin and lower half of face extending to the neck. The tongue was hard and edematous. As her symptoms worsened she asked for a piece of paper to write and wrote “VASOMOL”, which is a brand name for the hair dye containing paraphenelyenediamine. Conclusion The difficult airway management is an essential skill needed for the emergency physician. Hair dye poisoning has been known to cause severe angioneurotic odema. Ours is a case of PPD poisoning which presented with life threatening airway odema. We followed the ABCD assessment and on determining the need for airway control, we planned a surgical airway immediately.

Urticaria and, to a lesser extent, angioedema are common occurrences in the pediatric population. There are multiple causes of acute and chronic urticaria and angioedema. Most causes are benign, although they can be worrisome for patients and their parents. An allergist should evaluate acute urticaria and/or angioedema if there are concerns of an external cause, such as foods or medications. Chronic urticaria and angioedema can severely affect quality of life and should be managed aggressively with antihistamines and immunomodulators if poorly controlled. Chronic symptoms are unlikely to be due to an external cause. Anaphylaxis is a more serious allergic condition characterized by a systemic reaction involving at least 2 organ systems. Anaphylaxis should be initially managed with intramuscular epinephrine. Patients who experience anaphylaxis should be evaluated by an allergist for possible causes; if found, avoidance of the inciting antigen is the best management. All patients should also be given an epinephrine autoinjector and an action plan. Foods are a common cause of anaphylaxis in the pediatric population. New evidence suggests that the introduction of highly allergic foods is safe in infancy and should not be delayed. In addition, the early introduction of foods such as peanuts may help prevent the development of food allergies.

Background Besides hemorrhage, allergic reactions have also been observed in several clinical trials of fibrinolytic agents. These reactions might negatively affect patient outcomes, especially life-threatening type I hypersensitivity reactions such as anaphylaxis. However, there are limited data on the incidence of these reactions. Objective The aim of study was to analyze the incidence of urticaria, angioedema, and type I hypersensitivity reactions from fibrinolytic agents for various indications. Methods A retrospective analysis of data from the Thai Vigibase database was conducted. All reports of adverse drug reactions from fibrinolytic agents from 1984 to 2017 were identified using the World Health Organization adverse reaction terminology. The proportion of each suspected adverse drug reaction and the cumulative incidence were calculated. Results A total of 284 reports were identified in the Thai Vigibase database. The overall incidence of urticaria, angioedema, and type I hypersensitivity reactions for the streptokinase group was 52.64/10,000 persons, with individual incidence rates of 9.64/10,000 persons for urticaria, 8.90/10,000 persons for angioedema, and 34.11/10,000 persons for type I hypersensitivity reactions. In the alteplase group, the overall incidence for all suspected reactions was 18.90/10,000 persons, with individual incidence rates of 3.29/10,000 persons for urticaria, 5.75/10,000 persons for angioedema, and 9.86/10,000 persons for type I hypersensitivity reactions. Conclusions Type I hypersensitivity reactions were the most common allergic reactions from fibrinolytic agents. It is necessary to take these reactions into consideration when using fibrinolytic therapy.

BACKGROUND: Allergic contact dermatitis (ACD) is common in clinical practice, but the aetiology of this disease is quite varied. A leading pathogenetic mechanism is a cell-mediated immunity. The combinations of ACD with other allergic and systemic autoimmune diseases are relatively rare, but these conditions are undoubtedly a professional challenge for practitioners. CASE REPORT: We present a case of ACD combined with other immune-allergic conditions. Aetiology and pathogenesis in these cases are not well understood. CONCLUSION: Based on the data from the general and targeted allergic history, patient’s subjective complaints, clinical picture, allergenic status, paraclinical results, and the presented photo material, the final diagnosis is as follows: Contact allergic dermatitis-acute form.

Background Several clinical trials of fibrinolytic agents have reported the occurrence of allergic reactions, in addition to hemorrhage. These reactions might worsen patient outcomes, especially by causing life-threatening type I hypersensitivity reactions, including anaphylaxis; however, there is a scarcity of data in this regard. Objective This study described and characterized patients with urticaria, angioedema and type I hypersensitivity reactions caused by fibrinolytic agents. Methods This was a retrospective study in which cases of suspected adverse drug reactions from the use of streptokinase, alteplase, and tenecteplase were evaluated over a period of 10 years at Phramongkutklao and Ratchaburi hospitals in Thailand. In addition, patient characteristics and management were assessed. Results A total of 824 patients received fibrinolytic agents due to various indications. Of 147 patients who received streptokinase, nine (6.12%) had suspected adverse drug reactions (one case of urticaria, two cases of anaphylactic shock, and six cases of hypotension). The prescription rate of alteplase was the highest, being taken by 547 patients; however, only one patient (0.18%) reported an adverse reaction, angioedema in the face and lips. Similarly, of the 130 patients who received tenecteplase, only one patient (0.77%) developed hypotension. Conclusion All fibrinolytic agents, either nonfibrin or fibrin-specific, can cause urticaria, angioedema, and type I hypersensitivity reactions due to their mechanism of action.

Many notable advances in drug allergy, urticaria, angioedema, and anaphylaxis were reported in 2018. Broad-spectrum antibiotic use and, consequently, antibiotic resistance are widespread, and algorithms to clarify β-lactam allergy and optimize antibiotic use were described. Meaningful data emerged on the pathogenesis of delayed drug hypersensitivity reactions. Progress not only in defining biomarkers but also in understanding the effect on quality of life and developing better treatments has been made for patients with chronic idiopathic urticaria. Patients with hereditary angioedema (HAE) have gained additional access to highly efficacious therapies, with associated improvements in quality of life, and some progress was made in our understanding of recurrent angioedema in patients with normal laboratory results. Guidelines have defined clear goals to help providers optimize therapies in patients with HAE. The epidemiology and triggers of anaphylaxis and the mechanisms underlying anaphylaxis were elucidated further. In summary, these disorders (and labels) cause substantial burdens for individual persons and even society. Fortunately, publications in 2018 have informed on advancements in diagnosis and management and have provided better understanding of mechanisms that potentially could yield new therapies. This progress should lead to better health outcomes and paths forward in patients with drug allergy, urticaria, HAE, and anaphylaxis.

In the era of novel coronavirus epidemics, vaccines against coronavirus disease 2019 (COVID-19) have been recognized as the most effective public health interventions to control the pandemic. An adverse event following immunization (AEFI) is defined as any untoward occurrence following immunization, and the majority of AEFIs are caused by protective immune responses stimulated by vaccines. Most of the reported AEFIs are not serious, and many are not immunologically mediated or even reproducible on re-exposure. However, uncommon severe allergic adverse reactions, such as anaphylaxis or other allergic reactions, can occur after vaccinations. Confirmed allergic reactions to vaccines may be caused by residual non-human protein, preservatives, or stabilizers in the vaccine formulation (also known as excipients). There are 2 main potential allergenic/immunogenic excipients in COVID-19 vaccines, polyethylene glycol (PEG) and polysorbate 80. PEG, also known as macrogol, is an ingredient in various laxatives and injectable formulations, such as depot steroids. Polysorbate 80 is present in various medical products, creams, ointments, lotions, and medication tablets. Contraindications to the administration of COVID-19 vaccines include a previous history of severe allergic reactions to the first dose of COVID-19 vaccine or proven hypersensitivity to a vaccine component, such as PEG or polysorbate 80. Anaphylaxis or other allergic reactions following immunization can cause fear and loss of confidence in the safety of vaccines among the public. A better understanding of these events is thought to help alleviate concerns about the current COVID-19 vaccines and provide reassurance to the general population by analyzing the exact incidence of anaphylaxis and potential risk factors. COVID-19 vaccine-associated anaphylaxis could be prevented and managed by risk stratification based on our local and global experience.

Summary Objective. Drug use in athletes has been frequently investigated in the last three decades, especially regarding its misuse for doping. However, little is known about the use of permitted drugs for medical purposes and less studies have investigated the relationship between adverse drugs reactions (ADRs) and sports. Methods. An observational cross-sectional investigation analyzing a group of second league soccer players (the second-highest division in Italy) was performed. Anamnestic and physical examinations as well as a validated questionnaire (AQUA©) were performed in a group of 378 Italian second league soccer players. Results. Most players (91.8%) reported the use of NSAIDs in the previous year, and one third of them were regular users. Analgesics were used in 64% of the players, while 52.1% had taken antibiotics in the previous year. 29.20% of players used intraarticular treatments in the previous year. In 7,4% of players, an ADRs was reported: 3,47% reacted to NSAIDs, 2,6% to antibiotics, 1,05% to analgesics and 1 of them to supplements. For intra-articular injections, only 2 players experienced ADRs. One quarter of players experienced reactions as urticaria-angioedema syndrome or more severe conditions as bronchospasm or anaphylaxis. Conclusions. This study shows that drug misuse/abuse in soccer is a real matter of debate, especially with regards to NSAIDs, exposing athletes to predictable and/or unpredictable risks for their health.

BACKGROUND: Angioneurotic oedema (AE) is an unpredictable and dangerous disease directly threatening the patient's life due to a sudden onset of upper respiratory tract obstruction. The disease is associated with various causes and triggering factors, but little is known about the conditions that accompany AE. AIM: The study aims to determine the age-specificities and the spectrum of concomitant diseases in patients with AE. MATERIAL AND METHODS: The subjects of observation were 88 patients (53 women and 35 men) with angioneurotic oedema who underwent diagnostics and treatment in the Department of Occupational Diseases and Clinical Allergology of University hospital “Saint George”-Plovdiv. RESULTS: The highest level of disease prevalence was found in the age group over 50 years, both in males (45.71%) and females (54.72%). We found that the most often concomitant diseases in our patients with AE are cardiovascular (33%). On second place are the patients with other accompanying conditions outside of the target groups (27.3%). Patients with AE and autoimmune thyroiditis were 14.8%, and those with AE and skeletal-muscle disorders-10.2%. Given the role of hereditary factors in this disease, the profession of the patients is considered insignificant. CONCLUSION: Angioedema occurs in all age groups, but half of the cases are in people over 50 years of age. The most common concomitant diseases in angioedema are cardiovascular diseases.

Dermatologic emergencies represent about 8–20% of the diseases seen in the Emergency Department of hospitals. It is often a challenge for primary care physicians to differentiate mundane skin ailments from more serious, life threatening conditions that require immediate intervention. In this review we included the following conditions: Stevens-Johnson syndrome/toxic epidermal necrosis, pemphigus vulgaris, toxic shock syndrome, fasciitis necrotising, angioedema/urticaria, meningococcemia, Lyme disease and Rocky Mountain spotted fever.

Data of our 254 patients who were treated with rt-PA between 1st of Jan, 2011 and 31st of Dec, 2014 were processed. We focused on angioneurotic oedema as allergic complication of thrombolysis which caused life threatening respiratory obstruction in two cases. We describe these two patients' history. Out of 254 patients six (2.3%) suffered angioneurotic edema caused respiratory obstruction in two (0.90%) cases. This occurrence is approximately 1.3-5.1% in literature. Five, out of six patients who suffered from angioneurotic oedema, had been treated with ACE inhibitors or ARB before. The role of ACE inhibitors is known in metabolism of bradykinin cascade. Plasmin which present during thrombolysis, precipitates biochemical mechanisms of this potential life threatening complication. Therefore rt-PA alone can be the cause of angioedema, but it can be more frequent together with ACE inhibitors therapy.Osztályunkon ischaemiás stroke miatt végzett 254 thrombolysis kezelésének anyagát tekintettük át 2011. január 1- jétől 2014. december 31-ig. A kezelés kapcsán jelentkező allergiform szövődményeket vizsgáltuk, az angioneuroticus oedemára fókuszálva, mely két esetben életet veszélyeztető légúti obstrukcióhoz vezetett. A két kórtörténetet ismertetjük. A 254 betegből hat esetben (2,3%) angioneuroticus oedemát észleltünk, mely két esetben súlyos légúti obstrukciót okozott (0,90%). A nemzetközi irodalomban ez az előfordulási gyakoriság 1,3-5,1% között van. Az angioneuroticus oedemával járó esetekben egy beteg kivételével valamennyi szedett ACE-gátlót vagy ARB-t korábban. Az ACE-gátlók szerepe a bradikinin anyagcsere mechanizmusban való szerepe miatt ismert. A plazmin, mely a thrombolysiskezelés során keletkezik, szintén precipitálja a szövődményt okozó biokémiai mechanizmus beindítását. Emiatt szöveti plazminogénaktivátor (rt-PA) adása önmagában is okozhat angiooedemát, de ACE-gátló adása mellett ez gyakoribb lehet.

Angioedema in children displays a varied etiology and clinical manifestations, unlike adult angioedema. As opposed to angioedema in adults, pediatric angioedema majorly results from food, insect bites, and drugs. Reactions to insect bites, both allergic and toxic, are frequently encountered in pediatric medical practice but rarely seen in urological practice. Here, we present a case of penoscrotal angioedema resulting from an insect bite in the affected region. This case report emphasizes the need to consider penoscrotal angioedema as an important differential diagnosis of genital swelling, as early diagnosis may obviate fatal complications.

The article describes statistical data on patients with angioedema (AE) in the structure of ambulance services and four large multidisciplinary hospitals with otorhinolaryngological departments of the city of Moscow for 2017. The ratio of the number of calls to the NSR in Moscow for AE to the total number of calls was analyzed; the ratio of the number of calls to the ambulatory system for AE to the total number of calls to patients with allergic reactions; the ratio of patients with AE among the total number of treated patients in 3 hospitals in Moscow; the ratio of patients with AE of the upper respiratory tract (URT) among the total number of patients with AE; the ratio of patients with AE URT among the total number of patients with ENT pathology. As a result of the study, it was found that the share of AE in the structure of emergency calls of ambulance teams (В статье описаны статистические данные о больных ангеоневротическим отеком (АО) в структуре скорой медицинской помощи (СМП) и четырех крупных многопрофильных стационаров с оториноларингологическими отделениями Москвы за 2017 г. Проанализировано соотношение количества вызовов СМП в Москве по поводу АО к общему количеству вызовов; соотношение количества вызовов СМП по поводу АО к общему количеству вызовов к пациентам с аллергическими реакциями; соотношение больных АО среди общего числа пролеченных пациентов в 3 стационарах Москвы; соотношение больных АО верхних дыхательных путей (ВДП) среди общего числа пациентов с АО; соотношение пациентов с АО ВДП среди общего числа больных с ЛОР-патологией. В результате проведенного исследования было установлено, что доля АО в структуре экстренных вызовов бригад СМП (

Despite advances that have been made in our understanding of chronic urticaria/angioedema (CUA), many patients with CUA continue to experience poor control of their disease and severe impairment in their quality of life.1,2 More than half of patients may not achieve satisfactory control of CUA with antihistamine treatment.1,3 Urticaria and pruritus are promoted primarily by the action of histamine on H1 receptors located on endothelial cells (wheal) and on sensory nerves (flare); however, CUA is characterized by a nonnecrotizing perivascular infiltrate of CD4þ lymphocytes, monocytes, neutrophils, eosinophils, and basophils that can be recalcitrant to antihistamine therapydevenwhen advanced to high doses.1 Patients with CUA who do not respond to combination antihistamine therapy, with or without an antileukotriene, including dose advancement of a potent antihistamine (eg, doxepin at a dose of 75-125 mg/d) as tolerated, are considered to have antihistamine-resistant or refractory CUA.4 A number of therapeutic agents have been reported to be efficacious in patients with refractory CUA in case reports or case series.5,6 However, such studies may be subject to bias and do not provide high-quality evidence.7 Randomized controlled trials tend to be rated as high-quality evidence; however, the quality of evidence may be lowered based onmethodologic issues and other factors.8 Of the 4 agents for which randomized controlled trials in patients with refractory CUA have been reported (hydroxychloroquine,9 stanozolol,10 cyclosporine,11,12 and omalizumab13e16), cyclosporine and omalizumab are the only agents for which more than one randomized controlled trial has been published. In the 2014 update of the Urticaria/Angioedema Practice Parameter,4 a critical appraisal of the literature supporting the therapeutic utility of cyclosporine judged this evidence to be of low quality based on a number of methodologic shortcomings, leading to a weak recommendation for use of cyclosporine for refractory CUA. The weak recommendation does not imply that cyclosporine may not be of benefit in properly selected patients with refractory CUA or that it should not be prescribed. The weak recommendation signifies the need for clinicians to carefully consider whether administration of cyclosporine is favorable from the standpoint of balancing the potential for benefit with the potential for harm and discuss this with patients to determine that the decision to proceed with a trial of cyclosporine is consistent with their values and preferences. Omalizumab is a recombinant humanized monoclonal antibody approved by the US Food and Drug Administration (FDA) in 2003. It is the first monoclonal antibody approved for patients with allergic disorders. Omalizumab interrupts the allergic response at its primary step: the binding of allergen-specific IgE to mast cells.17 Its mechanism of action for asthma is thought to entail reduction of free IgE combined with down-regulation of expression of the high-affinity IgE receptor on basophils and mast cells.17 Salutary response to omalizumab in patients with refractory asthma has exhibited a gradual pattern of onset: 38% responding in 4 weeks and 62% after 16 weeks.18,19 This Clinical Perspective is intended to critically appraise the published evidence on omalizumab as a therapeutic intervention for patients with refractory CUA.

A 32-year-old man presented to the otorhinolaryngology emergency with complaints of sudden onset of foreign body sensation in his throat associated with drooling and muffled voice. The patient had consumed seafood (prawns) the previous night and woke up with the sensation of something ‘stuck’ in

Marijuana smoke can cause thermal injury, and since legalization and increased use of marijuana in our society, differentiating, diagnosing, and managing this condition have become mandatory. A case of a 28-year-old male with Quincke's disease secondary to marijuana inhalation is presented.

Paraphenylene diamine the content of most of the hair dye preparations is known to cause several local and systemic complications when ingested. Complications like angioedema, rhabdomyolysis, intravascular haemolysis, oliguria, acute tubular necrosis/acute renal failure are well known. Though cardiac complications has been reported but rarely in the literature. Here we report a case of hair dye poisoning presenting with angioneurotic oedema, oliguria, and myocarditis mimicking myocardial infarction as confirmed by ECG changes, cardiac biomarkers and echocardiographic findings.

P- Phenylenediamine is an oxidative chemical that is frequently used as a permanent hair-coloring agent. It is added to henna to increase the intensity and longevity of the tattoo and expedites its drying time. Henna itself is a greenish brown vegetable coloring made from the leaves of Lawsonia inermis and rarely causes allergic contact dermatitis. The addition of PPD causes the contact sensitization to black henna. Serious adverse skin reactions to permanent hair dyes and temporary black tattoos have been reported. As temporary tattoos have become fashionable among adolescents, the risk profile for p-phenylenediamine (PPD) sensitization of the population has changed simultaneously with an increasing use of hair dyes in this age group. With increased popularity of body art such as body piercing and tattooing, an increase in temporary henna tattoos has also occurred. Although the appeal of non-permanence exists for henna tattoos, dermatologists have begun to see numerous cases of allergic contact dermatitis linked with a certain type of henna. We selected 50 patients using hair dye and henna for our study. Patch testing was done in all the patients using Indian standard series of antigens. Regarding to the side effects to hair dye and henna and itching was the commonest symptom seen in 16% patients, erythematous scaly plaques were seen in 10% patients, vesicular reactions were seen in 6% patients, angioneurotic oedema and contact urticaria was seen in 4% patients each and anaphylaxis and keloidal reaction was seen in 2% patients each.

Para-phenylenediamine is widely used as a chemical in hair dyes and in combination with henna. This dye is used to paint the body for decorative reasons, to speed the processing time of henna and to intensify the results. Para-phenylenediamine is widely used in the Middle East, North Africa and India. Several reports have been published of the fatal ingestion of hair dye containing para-phenylenediamine. Here, we describe the case of a 14-year-old girl who ingested the compound but whose prompt treatment prevented her death. Ingestion of para-phenylenediamine produces a typical triad of angioneurotic oedema, rhabdomyolysis and acute tubular necrosis. Awareness of signs of these associated conditions in our patient, together with a comprehensive history, facilitated appropriate treatment to be instituted. We document the steps we took to enable her complete physical recovery.

The provocation test (PT) with the suspected drug represents the gold standard in the diagnosis of non-IgE hypersensitivity reactions to nonsteroidal anti-inflammatory drugs (NSAIDs). Nevertheless, there is no consensus regarding the clinical management of suspected NSAID-sensitive patients. This study assessed if a PT with the suspected drug is a reliable and safe proceeding to confirm NSAID hypersensitivity in patients with a clinical history of urticaria/angioedema (Urt/AE). It also analyzed different patient characteristics (such as gender, age, atopy, dermographism, time interval between the last drug reaction, and number of previous NSAID reactions) in relation to PT positivity. One hundred fifty-nine patients with Urt/AE apparently related to assumption of one or more NSAIDs underwent PT with the suspected drugs. Moreover, to distinguish single/multiple NSAID reactivity in patients who did not tolerate the offending NSAID, another strong cyclooxygenase-1 inhibitor PT was performed. PT was negative in 142/159 patients (89.31%), ruling out a diagnosis of NSAIDs hypersensitivity; 17/159 patients (10.69%) experienced a reaction of Urt/AE during the PT: 8 patients were diagnosed as single reactors to NSAIDs and 4 as multiple reactors to NSAIDs. Those with a history of multiple NSAID reactions and male patients were both more likely to have a positive PT. Our results suggest that in all patients with history of NSAID cutaneous reactions, the NSAID hypersensitivity should be confirmed by an oral PT and that the diagnostic proceeding can safely start with the offending NSAID.

Background In subjects with hypersensitivity reactions with cross-intolerance to nonsteroidal anti-inflammatory drugs (NSAIDs), tolerance to selective COX-2 inhibitors has not been evaluated in large series of well-phenotyped cases. Methods We evaluated 252 patients with urticaria and/or angioedema caused by hypersensitivity owing to cross-intolerance to NSAIDs. In addition to the clinical history, diagnosis was confirmed by provocation to an alternative NSAID. Two groups were considered: (A) patients with cross-intolerance to NSAIDs and intolerance to paracetamol and (B) patients with cross-intolerance to NSAIDs and good tolerance to paracetamol. Etoricoxib was administered to Group A patients and to a representative sample of Group B patients. In the event of a positive response, serum tryptase levels were determined and skin biopsy was performed in five patients in each group. Results Ibuprofen was the most commonly implicated drug, followed by acetylsalicylic acid (ASA). Urticaria was the most common manifestation, followed by angioedema. Most of the patients developed symptoms within 1 h. Twenty-five percent in Group A (n = 47) and 6% in Group B (n = 50) were intolerant to etoricoxib. Skin biopsy showed mast cell activation with the release of tryptase to the extracellular space but without the increase in serum tryptase levels. Conclusion Selective COX-2 inhibitors may be unsafe in subjects with urticaria and/or angioedema caused by hypersensitivity reactions to NSAIDs with cross-intolerance if they are intolerant to paracetamol. A quarter of patients who were intolerant to this drug were also intolerant to etoricoxib. In subjects with hypersensitivity to NSAIDs and intolerance to paracetamol, selective COX-2 inhibitors should be administered as a controlled, incremental dose provocation test to assess tolerance.

The apoprotein of hog kidney D-amino acid oxidase was reconstituted with 5-deazaflavin adenine dinucleotide (5-deazaFAD) to yield a protein which contains 1.5 mol of 5-deazaFAD/mol of enzyme. The deazaFAD-containing enzyme forms complexes with benzoate, 2-amino benzoate, and 4-aminobenzoate which are both qualitatively and quantitatively similar to those observed with native enzyme. The complex with 2-aminobenzoate exhibits a new long wavelength absorption band characteristic of a flavin charge-transfer complex. The reconstituted enzyme exhibits no activity when assayed by D-alanine oxidation. However, the bound chromophore can be reduced by alanine, phenylalanine, proline, methionine, and valine, but not by glutamate or aspartate, indicating the deazaFAD enzyme retains the substrate specificity of the native enzyme. Reduction of the enzyme by D-alanine exhibits a 1.6-fold deuterium isotope effect. Reoxidation of the reduced enzyme occurred in the presence of pyruvate plus ammonia, but not with pyruvate alone or ammonia alone. beta-Phenylpyruvate and alpha-ketobutyrate, but not alpha-ketoglutarate could replace pyruvate. Reduced enzyme isolated following reaction with [alpha-3H]alanine was found to contain 0.5 mol of tritium/mol of deazaFADH2. After denaturation of the tritium-labeled enzyme, the radioactivity was identified as deazaFADH2. Reaction of the reduced tritium-labeled enzyme with pyruvate plus ammonia prior to denaturation yields [alpha-3H]alanine and unlabeled deazaFAD. These results suggest that reduction and reoxidation of enzyme-bound deazaFAD involves the stereo-specific transfer of alpha-hydrogen from substrate to deazaFAD.